Provider Demographics
NPI:1548757073
Name:MAMMINO, JASON RYAN
Entity Type:Individual
Prefix:
First Name:JASON
Middle Name:RYAN
Last Name:MAMMINO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4344 WOODLANDS BLVD STE 160
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:CO
Mailing Address - Zip Code:80104-2801
Mailing Address - Country:US
Mailing Address - Phone:303-350-4500
Mailing Address - Fax:
Practice Address - Street 1:4344 WOODLANDS BLVD STE 160
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:CO
Practice Address - Zip Code:80104-2801
Practice Address - Country:US
Practice Address - Phone:303-350-4500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-19
Last Update Date:2023-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0066760207N00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207N00000XAllopathic & Osteopathic PhysiciansDermatology
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program